Proximal gastric vagotomy: follow-up at 10-20 years

Abdominal and dyspeptic symptoms in patients with peptic ulcer treated medically or surgically

BACKGROUND

Abdominal and dyspeptic complaints, which are prominent symptoms in patients with peptic ulceration, are commonly reported in the general population. There are few reports of follow-up study of peptic ulcer therapies in which clinical outcome has been compared with symptom reporting in community controls.

METHODS

Three populations of patients with peptic ulcer disease (patients who had elective proximal gastric vagotomy (PGV), those having PGV for emergency indications and those receiving medical treatment with H2-receptor antagonists) were included in a questionnaire survey and compared with a group of randomly selected community controls.

RESULTS

The vagotomized patients reported fewer abdominal complaints (P = 0.0003) and fewer dyspeptic complaints lasting for more than 1 week (P = 0.05) than those treated medically. There was no significant difference between vagotomized patients and community controls in the reporting of abdominal (P = 0.2) or dyspeptic (P = 0.9) complaints.

CONCLUSION

Taking abdominal complaints as the endpoint for former peptic ulcer treatment, surgical treatment with PGV seemed to be superior to therapy with H2-receptor antagonists and produced an almost identical level of complaints to that seen in the community population.

Lansoprazole, amoxicillin, and clarithromycin triple therapy in vagotomized patients with dyspeptic complaints. A randomized, double-blind, placebo-controlled, clinical study without pretreatment diagnostic upper endoscopy

BACKGROUND

The Maastricht Consensus Report advises that, in Helicobacter pylori-positive patients after surgery for peptic ulcer disease, H. pylori should be eradicated. The aim of the present study was to investigate the symptomatic response of H. pylori eradication in previously vagotomized peptic ulcer patients with persistent dyspeptic complaints.

METHODS

The study was performed as a randomized, double-blind, placebo-controlled study. Pretreatment diagnostic upper endoscopy was omitted. All the results were submitted to intention-to-treat and efficacy analyses.

RESULTS

We could not find any differences between the two groups with regard to intensity or frequency of upper abdominal pain, nausea, heartburn, or other abdominal symptoms during the 12-month follow-up. The triple therapy eradication rate was 88% at both 3- and 12-month controls.

CONCLUSION

Vagotomized peptic ulcer patients with persistent dyspeptic complaints should undergo a diagnostic upper endoscopy to detect ulcer recurrence before H. pylori eradication treatment is considered.

Long-term clinical results of highly selective vagotomy performed between 1980 and 1990

A retrospective analysis was conducted of 778 patients who underwent highly selective vagotomy between 1980 and 1990. Surgery was performed for duodenal ulcers without any complications in 485 (62.3%) patients; for duodenal ulcers with complications such as stenosis, bleeding, or perforation in 270 (34.7%); for combined duodenal and ventricular ulcers in 12 (1.5%), and for ventricular ulcers alone in 11 (1.4%). Pyloroplasty was additionally performed in the presence of complications only. The incidence of intraoperative complications proved to be as high as 1.4%, occurring in 11 patients, while postoperative complications developed in 247 patients (31.7%). Although the overall mortality was 0.6% (5 patients), the mortality rate of those patients who underwent surgery for uncomplicated ulcer disease was 0.2% only (2 patients). The patients comprised 554 men (71.2%) and 224 women (28.8%) with an average age of 41.4 +/- 0.7 years. The average duration of duodenal ulcer disease was 9.5 years, and 643 (83.2%) of the patients were able to be regularly followed up for between 3 and 13 years. Recurrence developed in 62 patients (9.6%): in the duodenum in 57 patients (91.9%), and in the stomach in 5 (8.1%). The rate of recurrence according to sex was 9.4% in men and 10.3% in women, being 42 and 20 patients, respectively. The average duration until recurrence appeared was 27.06 +/- 3.44 months. A reoperation proved necessary in 28 of these 62 patients (45.1%). The clinical results were evaluated by means of a modified Visick classification, according to which 81.8% of the patients belonged to groups 1 or 2, 7.9% to group 3, and 10.3% to group 4.

Long-term results of highly selective vagotomy: a prospective study with implications for future laparoscopic surgery

Between 1979 and 1984, 141 patients (110 men, 31 women) underwent highly selective vagotomy (HSV) by a standard open technique for duodenal ulcer. All patients had received preoperative treatment with full-dose H2-receptor antagonists. Some 107 of these patients underwent HSV for persistent relapse on withdrawal of H2-receptor antagonists (relapsing responders) and 30 because of non-response to such drugs. After 4 years of follow-up, non-responders were found to be more likely to have symptoms after operation (P < 0.001), but did not have a higher rate of recurrent ulceration. At a median of 11 (range 8-14) years after operation 126 patients were still alive; 115 (91 per cent) of these were followed up. Ten patients (9 per cent) were found to have had endoscopically proven recurrence and eight (7 per cent) still had symptoms without evidence of recurrence. The endoscopic recurrence rate and symptom rate at 11 years were no longer significantly different between relapsing responders and non-responders. The preoperative response to H2-receptor antagonist therapy does not help in predicting the likelihood of ulcer recurrence or long-term symptoms after HSV. Post-operative symptoms do not necessarily predict long-term ulcer recurrence. The long-term endoscopic recurrence rate after HSV is low and, if equally good results can be obtained laparoscopically, this will be an important and cost-effective option in the management of duodenal ulcer.

Laparoscopic highly selective vagotomy

Between February 1991 and August 1992, 35 patients underwent laparoscopic highly selective vagotomy (HSV) for recurrent duodenal ulcer disease. An antireflux procedure was also performed in 25 of these patients. There was no 30-day mortality and morbidity. The mean operating time was 110 (range 85-205) min for HSV and 155 (range 100-300) min for vagotomy and antireflux repair. Follow-up is short but initial postoperative gastric acid secretion studies have demonstrated results similar to those obtained after conventional open HSV. The main advantage of laparoscopic HSV is the reduction of 70 per cent in hospital stay and 50 per cent in the overall recovery period compared with open surgery.

Prepyloric antrectomy, truncal vagotomy, and front pylorotomy for the treatment of duodenal ulcer

We have performed a suprapyloric antrectomy with anterior pylorotomy and truncal vagotomy in 106 patients with chronic duodenal ulcer between 1975 and 1990. Follow-up was carried out in 94 patients, during a mean time of 6 years. We have had no postoperative mortality and no long-term recurrence. The percentage of Visick I patients is similar to that after truncal vagotomy and antrectomy. We, therefore, believe that this procedure is safe and can be performed when an antrectomy is mandatory to avoid the operative morbidity and mortality of classic antrectomy.

Functional evaluation of the intrathoracic stomach as an oesophageal substitute

A study of duodenogastric reflux and gastric function was undertaken in 16 patients 1-7 years after oesophagectomy and high intrathoracic oesophagogastrostomy for oesophageal carcinoma. All were able to eat satisfactorily; ten complained of mild foregut symptoms and ten had endoscopic mucosal lesions. Biliary excretion scintigraphy demonstrated pathological duodenogastric reflux in 11 patients. The emptying of a semisolid radiolabelled meal from the intrathoracic stomach in the upright position was significantly quicker than in control subjects (P less than 0.01). No gastric motor activity was recorded on manometry, suggesting that the transposed stomach acts like an inert tube. Results of 24-h pH monitoring showed that the area under the curve at pH less than 4 in the stomach was significantly less than in control subjects (P less than 0.001). In addition, patients had a significantly greater oesophageal alkaline exposure (P less than 0.001). The vagotomized intrathoracic stomach therefore empties well in the upright position, but is subjected to reflux of alkaline duodenal contents and can retain the ability to produce acid. The interaction between alkaline and acid contents in the pathogenesis of symptoms and mucosal lesions needs further investigation.

Postgastrectomy syndromes

Anatomic and physiological changes introduced by gastric surgery result in postgastrectomy syndromes in approximately 20% of patients. Most of these disorders are caused by operation-induced abnormalities in the motor functions of the stomach, including disturbances in the gastric reservoir function, the mechanical-digestive function, and the transporting function. Division of the vagal innervation to the stomach and ablation or bypass of the pylorus are the most significant factors contributing to postgastrectomy syndromes. Either rapid or slow emptying may result, depending on the relative importance of lack of a compliant gastric reservoir, loss of an effective contractile force, and loss of controlling factors that slow or speed gastric emptying and result in duodenal-gastric reflux. Clearly defining which syndrome is present in a given patient is critical to developing a rational treatment plan. In syndromes with slow gastric emptying, bilious vomiting, or alkaline reflux gastritis, the use of endoscopy is essential to rule out mechanical causes of the syndrome. Contrast radiography and scintigraphic gastric emptying studies are useful to document rapid or delayed gastric emptying. Postgastrectomy syndromes often abate with time. Conservative measures, including medical, dietary, and behavioral therapy, should be given at least a 1-year trial. If these nonoperative measures fail, surgical therapy is recommended. The Roux-en-Y gastrojejunostomy is useful for patients with dumping, because it slows gastric emptying and the transit of chyme through the Roux limb. The same operation helps patients with alkaline reflux gastritis, because it diverts pancreaticobiliary secretions away from the gastric remnant. Near-total gastrectomy, which reduces the size of a flaccid gastric reservoir, can be used to treat delayed gastric emptying. This operation should be combined with the Roux procedure to prevent postoperative reflux gastritis and esophagitis. Newer techniques, such as gastrointestinal pacing and the uncut Roux operation, may improve the treatment of the postgastrectomy syndromes in the future.